=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508953811
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VEGA LALIRE PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2006
-----------------------------------------------------
Last Update Date | 10/19/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 261 GREENWICH AVE
-----------------------------------------------------
City | GOSHEN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10924-2028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-615-1004
-----------------------------------------------------
Fax | 845-615-1029
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 SQUADRON BLVD
-----------------------------------------------------
City | NEW CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10956-5214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-213-1495
-----------------------------------------------------
Fax | 845-634-9424
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 008221
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------